1
|
Patrzalek P, Wysokinski WE, Kurmann RD, Houghton D, Hodge D, Kuczmik W, Klarich KW, Wysokinska EM. Cancer-associated non-bacterial thrombotic endocarditis-Clinical series from a single institution. Am J Hematol 2024; 99:596-605. [PMID: 38348537 DOI: 10.1002/ajh.27239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 03/19/2024]
Abstract
Premortem clinical presentation of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE), therapy, and the clinal course is limited to case reports and small clinical series. An electronic search of Mayo Clinic records (03/31/2002-06/30/2022) with a subsequent manual review was performed to identify adult patients with echocardiographically detected NBTE and active malignancy, excluding those with infectious endocarditis or lupus anticoagulant/antiphospholipid antibodies. In this retrospective cohort study, we analyzed 115 Ca-NBTE patients (mean age 63.2 ± 9.7 years, 66.1% female) involving 71 (61.7%) mitral, 58 (50.4%) aortic, 8 (6.9%) tricuspid, and 1 (0.9%) pulmonary valve. The most common cancer was lung (n = 45 cases (39.1%), followed by pancreatic (n = 19, 16.5%), gynecological (17, 14.8%), gastrointestinal (n = 10, 8.7%), and 10 (8.7%) with hematologic malignancy; 6 patients had two active cancers. Embolic complications at presentation were frequent: 94 (81.7%) brain, 11 splenic, 10 renal, 6 coronary, and 4 to the extremities. Of 104 anticoagulated patients, 60 received low molecular weight heparin, 17 unfractionated heparin, 16 apixaban, 8 warfarin, and 3 rivaroxaban. There were 18 arterial thromboembolisms; the Kaplan-Meier estimates of the incidence at 2 years were consistent with a rate of 15.9% [95% Confidence Interval (CI) 9.9-23.3], including 14 strokes (12.4%, 95%CI, 7.1-19.2), and 8 other arterial emboli (10.5%, 95%CI, 4.7-18.9); there were 10 venous thromboembolisms (8.9%, 95%CI, 4.5-15.0). Fourteen major bleedings occurred (12.8%, 95%CI, 7.3-19.9) and 94 patients died during follow-up (77.9%, 95%CI, 71.1-85.8). Ca-NBTE predominantly affected women with lung adenocarcinoma or digestive tract cancers and manifested by stroke with high mortality and frequent embolic and bleeding complications during anticoagulation therapy.
Collapse
Affiliation(s)
- Patryk Patrzalek
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar E Wysokinski
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Reto D Kurmann
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Damon Houghton
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Wiktoria Kuczmik
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Kyle W Klarich
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | | |
Collapse
|
2
|
Patrzałek P, Zawada T, Stolarski Ł, Kamińska M, Kaczmarek W. Non-bacterial Thrombotic Endocarditis (NBTE) in the Absence of Malignancy or Lupus Anticoagulant/Antiphospholipid Antibodies: A Case Report. Cureus 2024; 16:e59336. [PMID: 38817529 PMCID: PMC11137610 DOI: 10.7759/cureus.59336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
Non-bacterial thrombotic endocarditis (NBTE) is a very rare condition characterized by sterile thrombi formation on cardiac valves and is often associated with hypercoagulation states, such as malignancy and autoimmune disorders. We present the case of a 74-year-old patient admitted to the intensive care unit with acute respiratory failure, who had a history of COVID-19 infection five months prior to admission, despite having received certified vaccination. The patient developed NBTE involving the mitral valve, alongside acute respiratory distress syndrome (ARDS). In spite of the exclusion of cancer and systemic connective tissue disorders, the patient's condition rapidly deteriorated, leading to treatment-resistant multi-organ failure and demise, despite aggressive management, including anticoagulation therapy, mechanical ventilation, and renal replacement therapy. This case underscores the need for further research into the mechanisms underlying NBTE in the absence of traditional risk factors. Additionally, it highlights the importance of long-term anticoagulant therapy in NBTE management to mitigate the risk of embolic complications. Our case contributes to the growing body of literature identifying a subset of NBTE cancer-free patients with distinct characteristics, including those associated with current or past COVID-19 infection.
Collapse
Affiliation(s)
| | - Tomasz Zawada
- Intensive Care Unit, Rawicz District Hospital, Rawicz, POL
| | | | | | | |
Collapse
|
3
|
Tisch C, Ernst D, Falke M, Speicher P, Ziaka M. Systemic embolization due to non-bacterial thrombotic endocarditis: An autopsy case report and mini review of the literature. SAGE Open Med Case Rep 2024; 12:2050313X241229576. [PMID: 38292877 PMCID: PMC10826374 DOI: 10.1177/2050313x241229576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024] Open
Abstract
Nonbacterial thrombotic endocarditis is a rare, non-infectious complication associated with hypercoagulable states, such as malignancies and autoimmune diseases. Due to the difficulty distinguishing marantic endocarditis from infective endocarditis, the diagnosis is often delayed or even a postmortem finding. We present the case of a 70-year-old Caucasian female with marantic endocarditis secondary to metastatic duodenal adenocarcinoma. The patient presented with a short history of memory deficits, personality disturbances, and left homonymous hemianopia. Diffusion-weighted magnetic resonance imaging showed multi-territorial bihemispheric cerebral infarctions. Transthoracic echocardiography revealed native mitral valve endocarditis, and serial blood cultures remained negative. Despite antibiotic therapy, the patient's condition continuously deteriorated, and she died within 3 weeks after her initial presentation. Postmortem examination showed a non-bacterial thrombotic endocarditis. Early clinical suspicion and prompt diagnosis are of decisive importance for the survival of the patients.
Collapse
Affiliation(s)
- Carmen Tisch
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Daniel Ernst
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Monika Falke
- University of Bern, Institute of Tissue Medicine and Pathology, Bern, Switzerland
| | - Philip Speicher
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mairi Ziaka
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| |
Collapse
|
4
|
Nagao T, Sakamoto A, Fujihiro M, Kawakami R, Suwa K, Hattori K, Ohtani H, Saotome M, Baba S, V Finn A, Maekawa Y. Nonbacterial Thrombotic Endocarditis Caused by Early-stage Lung Cancer: An Autopsy Case Report. Intern Med 2024; 63:87-92. [PMID: 37164662 PMCID: PMC10824638 DOI: 10.2169/internalmedicine.2004-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/30/2023] [Indexed: 05/12/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a manifestation of prothrombotic status observed in patients with malignancy. Most cases are discovered only in the advanced stages. However, cancer in early stages may also induce NBTE development. We herein report an 87-year-old man with NBTE with multiple thromboembolization coexisting with lung cancer in early clinical stage. Autopsy findings revealed platelet- and fibrin-rich vegetations in both the tricuspid and mitral valves without evidence of bacterial infection. NBTE should be considered in cases with occult thromboembolization. Not only the presence of typical vegetation but irregular leaflet thickening should be monitored with careful echocardiographic examinations.
Collapse
Affiliation(s)
- Tomoaki Nagao
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Atsushi Sakamoto
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Mayu Fujihiro
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, Japan
| | | | - Kenichiro Suwa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Kazuya Hattori
- Department of Diagnostic Pathology, Shizuoka Saiseikai General Hospital, Japan
| | - Hayato Ohtani
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Masao Saotome
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Satoshi Baba
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, Japan
| | | | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| |
Collapse
|
5
|
Ahmad A, Golemi L, Bedi R, Sanfilippo KM, Poowanawittayakom N, Ou J. Non-bacterial thrombotic endocarditis in a patient with COVID. BMJ Case Rep 2023; 16:e256264. [PMID: 37865419 PMCID: PMC10603479 DOI: 10.1136/bcr-2023-256264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 10/23/2023] Open
Abstract
Non-bacterial thrombotic endocarditis is mainly associated with malignancies and rheumatological diseases. We report the case of mildly symptomatic COVID-19 infection with non-bacterial aortic valve vegetation complicated by transient ischemic attack (TIA) and pulmonary embolism during his hospitalisation. This case emphasised rare life-threatening complications from a hypercoagulable state related to COVID-19 infection. To the best of our knowledge, this is the third case report of non-bacterial endocarditis in a patient with COVID-19 patients as a potential rare complication of COVID-19.
Collapse
Affiliation(s)
- Ali Ahmad
- Department of Medicine, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Lolita Golemi
- Department of Medicine, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Rohil Bedi
- Department of Medicine, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Kristen M Sanfilippo
- Department of Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
- Department of Medicine, VA St Louis HealthCare System, Saint Louis, Missouri, USA
| | | | - Jiafu Ou
- Department of Medicine, Washington University in St. Louis School of Medicine, Saint Louis, Missouri, USA
- Department of Medicine, VA St Louis HealthCare System, Saint Louis, Missouri, USA
| |
Collapse
|
6
|
Parato VM, Belleggia S, Parato AG, Ianni U, Molisana M, Gizzi G, D'Agostino S, Dottori M, Di Eusanio M. Multi-valve Libman-Sacks's endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up. Monaldi Arch Chest Dis 2023. [PMID: 37817746 DOI: 10.4081/monaldi.2023.2729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/03/2023] [Indexed: 10/12/2023] Open
Abstract
We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up.
Collapse
Affiliation(s)
- Vito Maurizio Parato
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto; Post-Graduation School of Cardiovascular Diseases, School of Medicine, Università Politecnica delle Marche, Ancona.
| | - Sara Belleggia
- Post-Graduation School of Cardiovascular Diseases, School of Medicine, Università Politecnica delle Marche, Ancona.
| | | | - Umberto Ianni
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Michela Molisana
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Germana Gizzi
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Simone D'Agostino
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Melissa Dottori
- Cardiology Unit and Echolab, Cardiovascular Sciences Department, University Hospital Lancisi-Salesi, Ancona.
| | - Marco Di Eusanio
- Cardiac Surgery Unit and Cardiovascular Sciences Department, University Hospital Lancisi-Salesi, Università Politecnica delle Marche, Ancona.
| |
Collapse
|
7
|
Ikeda H, Ishibashi R, Kinosada M, Uezato M, Hata H, Kaneko R, Hayashi T, Yamashita H, Nukata R, Takada K, Kurosaki Y, Chin M, Yamagata S. Factors related to white thrombi in acute ischemic stroke in cancer patients. Neuroradiol J 2023; 36:453-459. [PMID: 36607169 PMCID: PMC10588610 DOI: 10.1177/19714009221150856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients. METHODS Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups. RESULTS There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 [95% confidence interval 1.71-368.99], p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity). CONCLUSIONS In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.
Collapse
Affiliation(s)
- Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
- Department of Neurosurgery, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Minami Uezato
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hidenobu Hata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Kaneko
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tomoko Hayashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Haruki Yamashita
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryotaro Nukata
- Department of Neurology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kensuke Takada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshitaka Kurosaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| |
Collapse
|
8
|
Akiki E, Ahmad A, El-Am EA, Casanegra AI, Klarich KW, Kurmann R. Case report: New is not always better: treatment of non-bacterial thrombotic endocarditis. Front Cardiovasc Med 2023; 10:1208190. [PMID: 37502185 PMCID: PMC10369060 DOI: 10.3389/fcvm.2023.1208190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
An elderly female with metastatic adenocarcinoma of the lung and atrial fibrillation presented with multiple embolic strokes while on anticoagulation with Apixaban. After further investigation, a TEE showed lesions of non-bacterial thrombotic endocarditis on the mitral valve. A decision to switch the patient to LMWH for anticoagulation was then made and a follow-up TEE showed resolution of the NBTE. In this abstract, we show that heparin should remain as the anticoagulation agent of choice in the setting of NBTE associated with malignancy.
Collapse
Affiliation(s)
- Elias Akiki
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Edward A. El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ana I. Casanegra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kyle W. Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Reto Kurmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
9
|
Rahouma M, Khairallah S, Dabsha A, Elkharbotly IAMH, Baudo M, Ismail A, Korani OM, Hossny M, Dimagli A, Girardi LN, Mick SL, Gaudino M. Lung Cancer as a Leading Cause among Paraneoplastic Non-Bacterial Thrombotic Endocarditis: A Meta-Analysis of Individual Patients' Data. Cancers (Basel) 2023; 15:cancers15061848. [PMID: 36980734 PMCID: PMC10047261 DOI: 10.3390/cancers15061848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Hypercoagulability is strongly associated with cancer and may result in non-bacterial thrombotic endocarditis (NBTE). The aim of our meta-analysis was to explore the demographics and characteristics of this condition in cancer. Databases were systematically searched. The outcomes were to identify the annual trend in premortem diagnosis among the entire cohort and different subgroups and to identify differences in characteristics and survival in the considered population. A total of 121 studies with 144 patients were included. The proportion of marantic endocarditis associated with lung cancer was 0.29 (95% CI, 0.21-0.37; p < 0.001), that associated with pancreatic cancer was 0.19 (95% CI, 0.13-0.27; p < 0.001), that associated with advanced cancer stage (metastasis) was 0.69 (95% CI, 0.61-0.76; p < 0.001), and that associated with adenocarcinoma was 0.65 (95% CI, 0.56-0.72; p < 0.001). Median and 6-month overall survival (OS) were 1.3 months and 32.3%, respectively, with 6-month OS of 20.8% vs. 37.0% in lung vs. other cancers, respectively (p = 0.06) and 42.9% vs. 31.1% among those who underwent intervention vs. those who did not (p = 0.07). Cases discovered in recent years had better survival (HR = 0.98 (95% CI, 0.96-0.99; p = 0.003). While cancer-associated NBTE is a rare entity, lung cancers were the most common tumor site and are frequently associated with more advanced and metastatic cancer stages. The prognosis is dismal, especially among lung cancers.
Collapse
Affiliation(s)
- Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Sherif Khairallah
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Anas Dabsha
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Ismail A M H Elkharbotly
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
- General Surgery Department, Newham University Hospital, London E13 8SL, UK
| | - Massimo Baudo
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Department of Cardiac Surgery, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Amr Ismail
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Omnia M Korani
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Mohamed Hossny
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| |
Collapse
|
10
|
Majdalany DS, Arsanjani R, Naqvi TZ. Light on valvular bumps. J Echocardiogr 2023; 21:45-47. [PMID: 34350556 DOI: 10.1007/s12574-021-00543-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Affiliation(s)
- David S Majdalany
- Department of Cardiovascular Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA.
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
| | - Tasneem Z Naqvi
- Department of Cardiovascular Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA
| |
Collapse
|
11
|
Stroke mortality in cancer survivors: A population-based study in Japan. Thromb Res 2023; 222:140-148. [PMID: 36682150 DOI: 10.1016/j.thromres.2023.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/22/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The association between cancer survivors and stroke deaths remains unclear. We aimed to evaluate the risk of fatal stroke in patients with cancer. MATERIALS AND METHODS This study was conducted using data from the Osaka Cancer Registry and vital statistics in Japan, collected from 1985 to 2013. We extracted patient data and investigated the causes of death. Standardized mortality ratios were calculated to compare the risk of stroke in patients with cancer to that in the general population. Poisson regression models were used to estimate the risk of stroke in patients with cancer and other cancer subgroups. Stroke types were used for risk stratification. RESULTS We identified 688,473 eligible patients with cancer. The cohort contributed 2,668,126 person-years at risk. During the study period, 337,117 patients died; stroke was the cause of death in 5496 patients. Stroke types included cerebral infarction (3259), intracerebral hemorrhage (1539), subarachnoid hemorrhage (364), and other cerebrovascular diseases (334). The crude mortality rate from fatal stroke was 205.99 per 100,000 person-years. The standardized mortality ratio (95 % confidence interval) for fatal stroke was 1.75 (1.71-1.80). When stratified by stroke types, the ratios for cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage were 1.83 (1.76-1.89), 2.38 (2.26-2.50), and 2.28 (2.03-2.56), respectively. The risk of fatal stroke increased with time after cancer diagnosis. The multivariate Poisson regression model indicated that men were more likely to die of stroke than women. CONCLUSIONS Cancer survivors have a higher risk of fatal stroke than the general population across all stroke types.
Collapse
|
12
|
Kania B, Mekheal E, Veeraballi S, Bondili L, Maroules M. A rare case of metastatic pancreatic adenocarcinoma presenting as a pulmonary embolism from nonbacterial thrombotic endocarditis. Radiol Case Rep 2022; 17:3097-3102. [PMID: 35784781 PMCID: PMC9240949 DOI: 10.1016/j.radcr.2022.05.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 12/03/2022] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) also called, "Marantic endocarditis" occurs due to an underlying hypercoagulable state causing tissue damage and upregulation of the coagulation cascade, with noninfective vegetation formation on heart valves. Mitral and aortic valves are most commonly involved. NBTE is rare, with an incidence of 1.6%, with 65 cases identified during a 10-year autopsy analysis. The most common malignancies associated with NBTE include gynecological cancers, lung cancer, gastric cancer, and pancreatic cancers with adenocarcinoma histology being the greatest risk. Herein, we present a rare case of a 55-year-old male who presented with acute hypoxic respiratory failure secondary to pulmonary embolism due to nonbacterial thrombotic endocarditis. He was found to have advanced pancreatic adenocarcinoma on further investigation of the 2.2 cm hypodense cystic mass in the distal pancreatic body and tail, and complex liver masses which were incidentally found on computed tomography angiography (CTA) of the chest. This is a rare phenomenon and clinicians have to consider the hypercoagulable state associated with cancers, particularly pancreatic adenocarcinoma, and the risk of NBTE.
Collapse
Affiliation(s)
- Brooke Kania
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
- Corresponding author.
| | - Erinie Mekheal
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
| | | | - Leena Bondili
- Department of Hematology-Oncology, St. Joseph's University Medical Center, Paterson, NJ 07503, USA
| | - Michael Maroules
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
- Department of Hematology-Oncology, St. Joseph's University Medical Center, Paterson, NJ 07503, USA
| |
Collapse
|
13
|
Cancer-associated non-bacterial thrombotic endocarditis. Thromb Res 2022; 213 Suppl 1:S127-S132. [DOI: 10.1016/j.thromres.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/13/2021] [Accepted: 11/23/2021] [Indexed: 01/09/2023]
|
14
|
Greer DM, Aparicio HJ, Siddiqi OK, Furie KL. Cardiac Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
15
|
Seki A, Fishbein MC. Age-related cardiovascular changes and diseases. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00004-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
|
16
|
Gray KM, Nguyen B, Baker L, Ahmad M. Non-bacterial thrombotic endocarditis and coronary thrombectomy in a patient with metastatic small cell lung carcinoma. BMJ Case Rep 2021; 14:14/6/e239893. [PMID: 34155006 DOI: 10.1136/bcr-2020-239893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 66-year-old Caucasian man was initially admitted with a metastatic small cell lung carcinoma, hyponatraemia and obstructive pneumonia. His transthoracic echocardiogram (TTE) was normal. Ten days after admission, he was diagnosed with a non-ST segment elevation myocardial infarction (MI). Both a repeated TTE and a transoesophageal echocardiogram identified thickened, myxomatous mitral valve leaflet tips with small, mobile masses identified as vegetations, and new, eccentric, severe mitral regurgitation. Subsequent cardiac catheterisation recorded thrombotic occlusion of the right coronary artery. Successful coronary thrombectomy was carried out, but the patient died. A diagnosis of non-bacterial thrombotic endocarditis leading to coronary embolisation and MI was made. The clinical course and treatment choices are discussed.
Collapse
Affiliation(s)
- Kelsey Margaret Gray
- School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Bao Nguyen
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Larissa Baker
- School of Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Masood Ahmad
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| |
Collapse
|
17
|
Tamura Y, Sakata K, Terada K, Usui S, Kawashiri MA, Takamura M. Treatment with a Direct Oral Anticoagulant for Nonbacterial Thrombotic Endocarditis. Intern Med 2021; 60:1881-1885. [PMID: 33456040 PMCID: PMC8263173 DOI: 10.2169/internalmedicine.6368-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We herein report a case of nonbacterial thrombotic endocarditis (NBTE) in a patient with previously undiagnosed lung cancer. A 62-year-old woman presented to our hospital with multiple cerebral infarctions. There was no evidence of valvular heart disease or vegetations. Whole-leg ultrasonography revealed deep vein thrombosis of the left peroneal vein. We administered direct oral anticoagulants (DOACs) for a presumed diagnosis of paradoxical embolisms caused by patent foramen ovale. Unfortunately, she experienced further embolization and died. At a postmortem examination, she was diagnosed with NBTE and metastatic adenocarcinoma of the lung. Our experience with this patient suggests that DOACs may be an insufficient treatment for NBTE.
Collapse
Affiliation(s)
- Yudai Tamura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Kazushi Terada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| |
Collapse
|
18
|
Savarapu P, Abdelazeem B, Isa S, Baral N, Hassan M. Cancer-Related Non-Bacterial Thrombotic Endocarditis Presenting as Acute Ischemic Stroke. Cureus 2021; 13:e14953. [PMID: 34123650 PMCID: PMC8190829 DOI: 10.7759/cureus.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 11/05/2022] Open
Abstract
Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare form of noninfectious endocarditis presenting with thromboembolism including ischemic cerebral stroke. It is mostly associated with advanced malignancy and characterized by the presence of sterile vegetation on heart valves. The diagnosis is usually based on vegetations seen on an echocardiogram, with negative blood cultures suggesting a noninfectious etiology. The treatment for this condition includes systemic anticoagulation. In this report, we discuss the case of a 61-year-old Caucasian female who presented to our facility with an ischemic stroke. She was found to have vegetations on the mitral valve with negative blood cultures. Further studies revealed metastatic pancreatic cancer. The patient's condition improved following in-hospital management, and she was discharged home for outpatient follow-up and treatment. Through this report, we highlight the importance of considering a search for malignancy in patients presenting with these clinical features. Early diagnosis and prompt management are critical to reduce the complications of NBTE and improve the patients' quality of life.
Collapse
Affiliation(s)
- Pramod Savarapu
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Basel Abdelazeem
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Sakiru Isa
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Nischit Baral
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Mustafa Hassan
- Cardiology, Michigan State University College of Human Medicine, Flint, USA
| |
Collapse
|
19
|
Chan KH, Joseph O, Ahmed E, Kommidi A, Suleiman A, Szabela ME, Slim J. Marantic Endocarditis Associated with COVID-19: A Rare Case Report of a Potentially Deadly Disease. Eur J Case Rep Intern Med 2021; 8:002409. [PMID: 33869101 DOI: 10.12890/2021_002409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 03/02/2021] [Indexed: 11/05/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has overwhelmed healthcare globally with millions of cases and over 2 million deaths worldwide. The hypercoagulable state associated with COVID-19 is a well-recognized complication that carries a poor prognosis. Marantic endocarditis, or non-bacterial thrombotic endocarditis (NBTE), is caused by a sterile vegetation on the cardiac valves resulting from the deposition of fibrin and platelet aggregates. It is highly associated with the hypercoagulable and acquired inflammatory states. Herein, we report a unique and rare case of COVID-19 presenting with NBTE. LEARNING POINTS COVID-19 has caused a major global pandemic, with high morbidity and mortality.One of the complications of COVID-19 infection is a hypercoagulable state.To the best of our knowledge, we present only the second case of marantic endocarditis in a patient with COVID-19, in the hope of raising awareness among physicians of this potential rare association.
Collapse
Affiliation(s)
- Kok Hoe Chan
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Ormena Joseph
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Eyad Ahmed
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Apoorva Kommidi
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Addi Suleiman
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Cardiology, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Maria E Szabela
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Jihad Slim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| |
Collapse
|
20
|
Gusdon AM, Farrokh S, Grotta JC. Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease. Semin Neurol 2021; 41:365-387. [PMID: 33851394 DOI: 10.1055/s-0041-1726331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.
Collapse
Affiliation(s)
- Aaron M Gusdon
- Department of Neurosurgery, UTHealth Neurosciences, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas
| | - Salia Farrokh
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Texas Medical Center, Houston
| |
Collapse
|
21
|
Abstract
Cancer and cancer therapies have the potential to affect the nervous system in a host of different ways. Cerebral edema, increased intracranial pressure, cerebrovascular events, status epilepticus, and epidural spinal cord compression are among those most often presenting as emergencies. Neurologic side-effects of cancer therapies are often mild, but occasionally result in serious illness. Immunotherapies cause autoimmune-related neurologic side-effects that are generally responsive to immunosuppressive therapies. Emergency management of neuro-oncologic problems benefits from early identification and close collaboration among interdisciplinary team members and patients or surrogate decision-makers.
Collapse
Affiliation(s)
- Zachary D Threlkeld
- Division of Neurocritical Care, Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive MC 5778, Stanford, CA 94305, USA
| | - Brian J Scott
- Division of Neurohospitalist Medicine, Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA 94305, USA.
| |
Collapse
|
22
|
Zmaili MA, Alzubi JM, Kocyigit D, Bansal A, Samra GS, Grimm R, Griffin BP, Xu B. A Contemporary 20-Year Cleveland Clinic Experience of Nonbacterial Thrombotic Endocarditis: Etiology, Echocardiographic Imaging, Management, and Outcomes. Am J Med 2021; 134:361-369. [PMID: 32827467 DOI: 10.1016/j.amjmed.2020.06.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 06/24/2020] [Accepted: 06/29/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nonbacterial thrombotic endocarditis, or marantic endocarditis, is rare. Contemporary data on the etiology, echocardiographic evaluation, and management of nonbacterial thrombotic endocarditis are limited. METHODS A single-center retrospective cohort study was performed. Electronic medical records and echocardiographic records were searched for patients ages ≥18 years with a confirmed diagnosis of nonbacterial thrombotic endocarditis between January 1999 and November 2019. Demographic, echocardiographic, and management data were collected. RESULTS Of 600,577 transthoracic echocardiograms (TTEs) and 89,264 transesophageal echocardiograms (TEEs), 42 patients had nonbacterial thrombotic endocarditis (mean age: 54 ± 14.5 years; 66.7% were female). The median duration of follow-up was 8.2 (interquartile range 3.3-24.4) months. Seventeen patients (40.5%) had malignancy, 33.3% had systemic lupus erythematosus, and 35.7% had antiphospholipid antibody syndrome. Stroke was the most common presentation (59.5%). TTE enabled the diagnosis in 19 cases (45.2%), compared with TEE, which identified the condition in 33 of 34 (97.1%) cases in which it was utilized. Three-dimensional echocardiography was performed in 17 TEEs. The most common valves involved were mitral (61.9%), and aortic (23.8%) valves. Thirty-two patients were managed with anticoagulation. Ten patients underwent surgery. Sixteen (38.1%) patients died, most of whom had a diagnosis of advanced malignancy. CONCLUSION In a contemporary 20-year cohort, TTE and TEE played important roles in diagnosis, with superior diagnostic performance of TEE for nonbacterial thrombotic endocarditis. Mortality was high, and advanced malignancy portended a worse prognosis. Management in most cases was therapeutic anticoagulation. In select cases, surgery provided favorable outcomes.
Collapse
Affiliation(s)
| | - Jafar M Alzubi
- Department of Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Duygu Kocyigit
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Agam Bansal
- Department of Medicine, Cleveland Clinic, Ohio
| | | | - Richard Grimm
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio.
| |
Collapse
|
23
|
Dafer RM. Neurologic complications of nonbacterial thrombotic endocarditis. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:135-141. [PMID: 33632431 DOI: 10.1016/b978-0-12-819814-8.00013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endocarditis is an inflammatory or infective condition affecting the cardiac valves or endocardium, often associated with serious neurological sequelae. Nonbacterial thrombotic endocarditis (NBTE)-referred to as degenerative, Libman-Sachs, marantic, verrucous, or terminal endocarditis-is a serious but rare cause of valvular heart disease characterized by deposition of sterile vegetations of fibrin and platelet aggregates on the cardiac valves, eventually resulting in life-threatening embolization of these thrombi to the brain, limbs, or visceral organs. NBTE may complicate a heterogeneous group of chronic conditions, predominantly connective tissue and autoimmune disorders, malignancies, and diseases associated with hypercoagulability states. NBTE usually affects the native rather than prosthetic valves, and unlike infective endocarditis (IE), sparing the involved valve function without its destruction. Compared to those seen in IE, vegetations in NBTE are small and friable, thus may easily be dislodged leading to systemic thromboembolism with devastating morbidities and mortality. There are no diagnostic criteria for NBTE, and antemortem diagnosis is challenging. The condition should be suspected in patients with thromboembolic events and vegetations on the cardiac valves on echocardiographic or cardiac imaging studies, in the absence of underlying infection, especially in disorders predisposing to coagulopathy. Early recognition and prompt treatment of the primary underlying disorder is essential. Anticoagulation with heparin or heparinoid products is recommended to prevent recurrent embolism. Surgical intervention is not indicated except in selected patients with life-threatening recurrent embolism.
Collapse
Affiliation(s)
- Rima M Dafer
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
| |
Collapse
|
24
|
Garcia RA, Guragai N, Vasudev R, Randhawa P, Habib MG. Rare Association of Non-Bacterial Thrombotic Endocarditis, Myocardial Infarction, and Acute Limb Ischemia Secondary to Rheumatoid Arthritis: Comprehensive Case Series With Literature Review. Cureus 2021; 13:e13319. [PMID: 33747642 PMCID: PMC7962500 DOI: 10.7759/cureus.13319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Most cases of non-bacterial thrombotic endocarditis (NBTE) tend to be related to malignancy or rheumatologic and autoimmune disorders like systemic lupus erythematosus. Rheumatoid arthritis (RA) itself has been associated with increased atherosclerosis, coronary artery plaque formation, and endothelial damage. However, it is rare to see NBTE in RA, simultaneously presenting with the acute coronary syndrome and acute limb ischemia due to distant embolization. Here we present a case of a 46-year-old female presenting with chest pain and right leg numbness, found to have ST-elevation myocardial infarction (STEMI) and occlusion of a peripheral artery due to embolization of vegetation present in the aortic valve. We also provide an extensive literature review of the relationship between NBTE and MI. One must be extra vigilant in managing these patients, especially if the size of vegetation is large as it has a tendency to embolize causing devastating complications.
Collapse
Affiliation(s)
| | - Nirmal Guragai
- Cardiology, Saint Joseph's Regional Medical Center, Paterson, USA
| | - Rahul Vasudev
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Preet Randhawa
- Cardiology, Trinitas Regional Medical Center, Elizabeth, USA.,Cardiology, Saint Michael's Medical Center, Newark, USA
| | | |
Collapse
|
25
|
Kijpaisalratana N, Chutinet A, Travanichakul S, Kitjawijit T, Yokumporn P, Duangjino K, Suwanwela NC. Nonbacterial Thrombotic Endocarditis Related to Adenocarcinoma of the Uterine Cervix. Case Rep Neurol 2021; 12:183-188. [PMID: 33505293 DOI: 10.1159/000507277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 03/13/2020] [Indexed: 11/19/2022] Open
Abstract
We report a 66-year-old female patient who presented with acute onset of visual loss with relative afferent pupillary defect, hemineglect, hemihypesthesia, and apraxia. Magnetic resonance imaging of the brain demonstrated different stages of ischemic stroke in different vascular territories, suggesting cardiogenic embolism. Past history was significant for advanced-stage adenocarcinoma of the uterine cervix under chemoradiation treatment. On echocardiogram, vegetation at the aortic valve was observed. With the absence of evidence of infectious endocarditis, diagnosis of nonbacterial thrombotic endocarditis was made, and the patient was treated by long-term anticoagulant. This case is unique in terms of the adenocarcinoma cell type of cervical cancer, which is uncommon and has been rarely reported to be related to nonbacterial thrombotic endocarditis.
Collapse
Affiliation(s)
- Naruchorn Kijpaisalratana
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Chula Neuroscience Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Division of Academic Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aurauma Chutinet
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Chulalongkorn Comprehensive Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suporn Travanichakul
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Chulalongkorn Comprehensive Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Teeraparp Kitjawijit
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Chulalongkorn Comprehensive Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pajaree Yokumporn
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kotchakorn Duangjino
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nijasri C Suwanwela
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Chulalongkorn Comprehensive Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| |
Collapse
|
26
|
Patel MJ, Elzweig J. Non-bacterial thrombotic endocarditis: a rare presentation and literature review. BMJ Case Rep 2020; 13:13/12/e238585. [PMID: 33318278 PMCID: PMC7737039 DOI: 10.1136/bcr-2020-238585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A 66-year-old woman with a remote history of breast cancer and prior tobacco use presented to the hospital with chest pain. She was found to have an elevated troponin consistent with a diagnosis of a non-ST segment elevation myocardial infarction (NSTEMI). A left heart catheterisation revealed non-obstructive coronary disease, and subsequent transthoracic and transoesophageal echocardiograms demonstrated vegetations on both the mitral and aortic valves. Multiple blood cultures showed no growth raising suspicion for non-bacterial thrombotic endocarditis (NBTE). A CT of the chest, abdomen and pelvis was obtained that was consistent with metastatic pancreatic cancer. Her hospital course was complicated by recurrent embolic strokes leading to a rapid clinical deterioration. As a result, she was transitioned to comfort measures and passed away shortly thereafter. To our knowledge, this is the first reported case of an NSTEMI as the initial presentation of NBTE due to underlying malignancy.
Collapse
Affiliation(s)
- Maulin J Patel
- Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Joel Elzweig
- Medicine Institute, Geisinger Medical Center, Danville, Pennsylvania, USA
| |
Collapse
|
27
|
Trousseau's syndrome associated with rapidly emerging pancreatic adenocarcinoma soon after esophagectomy: A case report. Int J Surg Case Rep 2020; 77:605-609. [PMID: 33395856 PMCID: PMC7708758 DOI: 10.1016/j.ijscr.2020.11.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022] Open
Abstract
The first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered esophagectomy. The aggressively emerging pancreatic cancer with mucin production may be a potential mechanism for cancer-related thrombosis. When a patient with cancer encountered small, multiple cerebral infarctions postoperatively, the body should be checked for occult malignancy.
Introduction Trousseau’s syndrome is characterized as an unexpected, cancer-associated thrombotic event. We describe the first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered by esophagectomy. Presentation of case A 79-year-old asymptomatic male with clinical stage I esophageal squamous cell carcinoma underwent thoracoscopic subtotal esophagectomy. On postoperative day 46, the patient presented with weakness of his left upper extremity due to multiple cerebral and cerebellar infarctions, with no evidence of atherosclerotic or cardiogenic thrombi. An abdominal computed tomography (CT) showed a pancreatic tumor with multiple liver metastases. Extremely high D-dimer and the CT findings suggested Trousseau’s syndrome associated with a rapidly emerging neoplasm as the etiology of the brain infarction. Although further thrombotic events did not occur, his condition deteriorated rapidly and died on the 31st days of onset. The autopsy revealed multiple small infarctions, with multiple thrombi in the cerebral hemispheres, brain stem, and cerebellum. Histological evaluation revealed pancreatic adenocarcinoma with nodal and liver metastases. Discussion A hypercoagulable state associated with the aggressively emerging pancreatic adenocarcinoma, accompanied by cancer cell production of mucin, may be a potential mechanism for cancer-related thrombosis. Conclusion In patients who received intensive surgical treatment and encountered unexplained brain infarctions in the multi-arterial territory, Trousseau’s syndrome should be considered, and investigation for occult malignancy is required.
Collapse
|
28
|
Wang J, Monga N, Mopala P, Husnain M. Development of Nonbacterial Thrombotic Endocarditis While on Systemic Anticoagulation in Pancreatic Cancer: A Case Report. Cureus 2020; 12:e10967. [PMID: 33209525 PMCID: PMC7667603 DOI: 10.7759/cureus.10967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Nonbacterial thromboembolic endocarditis (NBTE), or marantic endocarditis, is a rare complication associated with advanced cancer. Enoxaparin or unfractionated heparin is considered the standard treatment for NBTE. In this case report, we describe a 59-year-old female with metastatic pancreatic cancer who presented with embolic stroke and was found to have new NBTE of the mitral valve while she was receiving the therapeutic dose of enoxaparin. Of note, her recent echocardiogram one week ago was negative for mitral valve vegetations. Our case emphasized that for patients with advanced cancer presenting with stroke, the diagnosis of NBTE should be entertained even for those on systemic anticoagulation.
Collapse
Affiliation(s)
- Jiasheng Wang
- Department of Internal Medicine, MetroHealth Medical Center, Cleveland, USA
| | - Natasha Monga
- Department of Radiology, MetroHealth Medical Center, Cleveland, USA
| | - Prashanth Mopala
- Department of Cardiology, MetroHealth Medical Center, Cleveland, USA
| | - Muhammad Husnain
- Department of Medicine, MetroHealth Medical Center, Cleveland, USA
| |
Collapse
|
29
|
Yoo J, Choi JK, Kim YD, Nam HS, Park H, Lee HS, Heo JH. Outcome of Stroke Patients with Cancer and Nonbacterial Thrombotic Endocarditis. J Stroke 2020; 22:245-253. [PMID: 32635688 PMCID: PMC7341006 DOI: 10.5853/jos.2020.00619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/21/2020] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose Nonbacterial thrombotic endocarditis (NBTE) is a cause of stroke in cancer. However, clinical characteristics and outcomes in stroke patients with cancer-associated NBTE are not well known. Methods We included consecutive patients with stroke and active cancer over a 9-year period who underwent echocardiography. We retrospectively compared clinical characteristics and presence of metastasis between patients with NBTE, those with cryptogenic etiologies, and those with determined etiologies. We also investigated mortality and stroke events during the 6-month follow-up. Results Among the 245 patients, 20 had NBTE, 96 had cryptogenic etiologies, and 129 had determined etiologies. Metastasis was seen in all 20 patients (100%) with NBTE, 69.8% in patients with cryptogenic etiology, and 48.8% in patients with or determined etiology. During the 6-month follow-up, 127 patients (51.8%) developed stroke and/or died (death in 110 [44.9%] and stroke events in 55 [22.4%]). Patients with NBTE showed significantly higher mortality (80%) and stroke occurrence (50%) than those with cryptogenic etiologies (mortality 54.2%, stroke 25.0%, log-rank P=0.006) and determined etiologies (mortality 32.6%, stroke 16.3%, log-rank P<0.001). In a multivariate Cox proportional hazard analysis, the presence of NBTE was independently associated with composite outcomes of mortality and stroke events (hazard ratio, 1.941; 95% confidence interval, 1.052 to 3.690). Conclusions NBTE should be suspected as a potential cause of stroke in patients with metastatic cancer. Patients with NBTE have a high risk of recurrent stroke and mortality. Future studies are necessary to determine strategies to reduce stroke recurrence in patients with NBTE.
Collapse
Affiliation(s)
- Joonsang Yoo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.,Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungjong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
30
|
|
31
|
Kaufmann CC, Wessely E, Huber K. Non-bacterial thrombotic endocarditis in the context of pulmonary adenocarcinoma: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 32128491 PMCID: PMC7047059 DOI: 10.1093/ehjcr/ytaa008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/28/2019] [Accepted: 12/10/2019] [Indexed: 11/16/2022]
Abstract
Background Non-bacterial thrombotic endocarditis (NBTE) is a rare condition, usually observed in association with malignancy, lupus erythematosus, or antiphospholipid syndrome. Diagnosis of NBTE remains a challenge as patients are often asymptomatic up to their first thromboembolic event. While there is no randomized data available for the guidance of treatment in NBTE, effective anticoagulation remains the main focus in the management of affected patients. Case summary A 44-year-old female patient without a significant medical history presented to the emergency department with a new numbness of her right hand. Magnetic resonance imaging scans facilitated the diagnosis of supratentorial stroke. Within the next 3 months, the patient had multiple thromboembolic events, including multiple strokes, pulmonary embolism, and renal/splenic infarction. Echocardiographic examination revealed large, transient vegetations of the aortic valve with concomitant aortic regurgitation. In addition, an incidental, pulmonary non-small-cell adenocarcinoma was found during the diagnostic work-up. Infective endocarditis was excluded by several negative blood cultures and missing signs of infection. Hence, the diagnosis of NBTE secondary to malignancy was made. Discussion We present a rare case of NBTE in the context of pulmonary adenocarcinoma. The adequate treatment of malignancy and effective anticoagulation are the main treatment options.
Collapse
Affiliation(s)
- Christoph C Kaufmann
- 3rd Medical Department of Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, Austria
| | - Emil Wessely
- 3rd Medical Department of Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, Austria
| | - Kurt Huber
- 3rd Medical Department of Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| |
Collapse
|
32
|
Heo JH, Nam HS, Kim YD, Choi JK, Kim BM, Kim DJ, Kwon I. Pathophysiologic and Therapeutic Perspectives Based on Thrombus Histology in Stroke. J Stroke 2020; 22:64-75. [PMID: 32027792 PMCID: PMC7005358 DOI: 10.5853/jos.2019.03440] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/23/2020] [Indexed: 01/04/2023] Open
Abstract
Recent advances in endovascular thrombectomy have enabled the histopathologic analysis of fresh thrombi in patients with acute stroke. Histologic analysis has shown that the thrombus composition is very heterogeneous between patients. However, the distribution pattern of each thrombus component often differs between patients with cardiac thrombi and those with arterial thrombi, and the efficacy of endovascular thrombectomy is different according to the thrombus composition. Furthermore, the thrombus age is related to the efficacy of reperfusion therapy. Recent studies have shown that neutrophils and neutrophil extracellular traps contribute to thrombus formation and resistance to reperfusion therapy. Histologic features of thrombi in patients with stroke may provide some clues to stroke etiology, which is helpful for determining the strategy of stroke prevention. Research on thrombus may also be helpful for improving reperfusion therapy, including the development of new thrombolytic agents.
Collapse
Affiliation(s)
- Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea.,Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Kwon
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
33
|
Park H, Kim J, Ha J, Hwang IG, Song TJ, Yoo J, Ahn SH, Kim K, Kim BM, Kim DJ, Kim YD, Nam HS, Kwon I, Choi HJ, Sohn SI, Lee HS, Heo JH. Histological features of intracranial thrombi in stroke patients with cancer. Ann Neurol 2019; 86:143-149. [PMID: 31025392 DOI: 10.1002/ana.25495] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 12/21/2022]
Abstract
The histological features of thrombus in stroke patients with cancer are not well known. Using immunohistochemical staining of thrombi retrieved during mechanical thrombectomy in stroke patients, thrombus compositions were compared between 16 patients with active cancer, 16 patients with inactive cancer, and 16 patients without any history of cancer. The active cancer group showed higher platelet and lower erythrocyte fractions than the inactive cancer or the control group. Four patients with vegetation showed very high platelet and low erythrocyte fractions. Patients with cryptogenic etiology in the active cancer group showed a similar pattern to those with vegetation. These findings may aid the determination of treatment strategies in cancer-associated stroke. ANN NEUROL 2019.
Collapse
Affiliation(s)
- Hyungjong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Jayoung Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jimin Ha
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - In Gun Hwang
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwanju, Korea
| | - Kyoungsub Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Kwon
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Jung Choi
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei Universeity College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
34
|
Dardiotis E, Aloizou AM, Markoula S, Siokas V, Tsarouhas K, Tzanakakis G, Libra M, Kyritsis AP, Brotis AG, Aschner M, Gozes I, Bogdanos DP, Spandidos DA, Mitsias PD, Tsatsakis A. Cancer-associated stroke: Pathophysiology, detection and management (Review). Int J Oncol 2019; 54:779-796. [PMID: 30628661 PMCID: PMC6365034 DOI: 10.3892/ijo.2019.4669] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022] Open
Abstract
Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.
Collapse
Affiliation(s)
- Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Athina-Maria Aloizou
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, 45110 Ioannina
| | - Vasileios Siokas
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | | | - Georgios Tzanakakis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Massimo Libra
- Department of Biomedical and Biotechnological Sciences, Pathology and Oncology Section, University of Catania, 95124 Catania, Italy
| | | | - Alexandros G. Brotis
- Department of Neurosurgery, University of Thessaly, University Hospital of Larissa, 41100 Larissa, Greece
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Illana Gozes
- The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, The Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Sagol School of Neuroscience and Adams Super Center for Brain Studies, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 40500 Larissa
- Cellular Immunotherapy and Molecular Immunodiagnostics, Biomedical Section, Centre for Research and Technology-Hellas (CERTH) - Institute for Research and Technology-Thessaly (IRETETH), 41222 Larissa
| | | | - Panayiotis D. Mitsias
- Department of Neurology, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Comprehensive Stroke Center and Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Aristidis Tsatsakis
- Laboratory of Toxicology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| |
Collapse
|
35
|
Neilson LE, Rogers LR, Sundararajan S. Evaluation and Treatment of a Patient With Recurrent Stroke in the Setting of Active Malignancy. Stroke 2019; 50:e9-e11. [PMID: 30580735 DOI: 10.1161/strokeaha.118.022088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Lee E Neilson
- From the Neurological Institute, University Hospitals Cleveland Medical Center, OH
| | - Lisa R Rogers
- From the Neurological Institute, University Hospitals Cleveland Medical Center, OH
| | - Sophia Sundararajan
- From the Neurological Institute, University Hospitals Cleveland Medical Center, OH
| |
Collapse
|
36
|
Shibata N, Matsumoto K, Kitamura S, Sakashita A, Kizawa Y, Hirata KI. Nonbacterial Thrombotic Endocarditis Concomitant with Repeated Systemic Embolization That Received Palliative Care Based on the Antemortem Diagnosis. Intern Med 2018; 57:3559-3563. [PMID: 30101943 PMCID: PMC6355422 DOI: 10.2169/internalmedicine.1381-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A 67-year-old woman was admitted to our hospital due to an acute onset of consciousness disturbance, aphasia and left hemiplegia. Computed tomography revealed multiple systemic infarctions, including brain, kidney and spleen. Transesophageal echocardiography revealed vegetations attached to the mitral valve leaflets, which was suspected to be the embolic source. Repeated blood cultures were negative, and advanced lung cancer was incidentally revealed by computed tomography. She was then diagnosed with nonbacterial thrombotic endocarditis (NBTE) based on the overall clinical picture. Subsequently, extensive systemic embolization repeatedly occurred, and she eventually died 25 days after admission. The autopsy proved NBTE and advanced-stage lung adenocarcinoma.
Collapse
Affiliation(s)
- Nao Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kensuke Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Satoru Kitamura
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Japan
| | - Akihiro Sakashita
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| |
Collapse
|
37
|
Les endocardites non infectieuses. Rev Med Interne 2018; 39:782-791. [DOI: 10.1016/j.revmed.2018.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 02/05/2018] [Accepted: 03/03/2018] [Indexed: 12/18/2022]
|
38
|
Sirinvaravong N, Rodriguez Ziccardi MC, Patnaik S, Shah M, Fernandez G, Aliling JN, Rubin A. Nonbacterial thrombotic endocarditis in a patient with primary antiphospholipid syndrome. Oxf Med Case Reports 2018; 2018:omy024. [PMID: 29977578 PMCID: PMC6016692 DOI: 10.1093/omcr/omy024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/09/2018] [Accepted: 04/16/2018] [Indexed: 11/24/2022] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is described in patients with mucin-producing cancers and connective tissue disorders (usually SLE). We report NBTE in the setting of primary antiphospholipid antibody syndrome (APS). A 65-year-old female with APS was incidentally found to have thickened mitral leaflets on transthoracic echocardiogram with no signs of infection. Transesophageal echocardiogram (TEE) showed a mobile mitral mass (1.4 × 0.7 cm) and moderate mitral regurgitation. Differential diagnoses included bacterial endocarditis, NBTE, thrombus or tumor. Given the history of primary APS, the absence of fever and negative blood cultures, NBTE was considered. Low-molecular-weight heparin, hydroxychloroquine and corticosteroid were initiated. Repeat TEE in a week revealed shrinkage of the mass (0.6 × 0.7 cm), indicating an inflammatory nature. Lifelong anticoagulation is indicated regardless of embolism occurrence. Hydroxychloroquine and corticosteroids may have roles in the treatment. Determining and treating the underlying etiology is important.
Collapse
Affiliation(s)
| | | | - Soumya Patnaik
- Division of Cardiology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mahek Shah
- Division of Cardiology, Lehigh Valley Healthcare Network, Allentown, PA, USA
| | - Gustavo Fernandez
- Division of Pulmonology, Temple University Hospital, Philadelphia, PA, USA
| | | | - Alexander Rubin
- Division of Cardiology, Pennsylvania Heart and Vascular Group, Jenkintown, Philadelphia PA, USA
| |
Collapse
|
39
|
Navi BB, Iadecola C. Ischemic stroke in cancer patients: A review of an underappreciated pathology. Ann Neurol 2018; 83:873-883. [PMID: 29633334 PMCID: PMC6021225 DOI: 10.1002/ana.25227] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
Currently 1 in 10 patients with ischemic stroke have comorbid cancer, and this frequency is expected to increase with continued advances in cancer therapeutics prolonging median survival. Well known for its association with venous thrombosis, cancer has recently emerged as a significant risk factor for arterial thromboembolism, including stroke; however, the underlying mechanisms are uncertain. In addition, the optimal strategies to prevent and acutely treat stroke in cancer patients are yet to be established. This review summarizes the current evidence on ischemic stroke risk, biomarkers, pathophysiology, treatments, and prognosis in cancer patients, emphasizing knowledge gaps and the potential strategies to address them. Ann Neurol 2018;83:873-883.
Collapse
Affiliation(s)
- Babak B Navi
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Costantino Iadecola
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| |
Collapse
|
40
|
Tilemann LM, Heckmann MB, Katus HA, Lehmann LH, Müller OJ. Cardio-oncology: conflicting priorities of anticancer treatment and cardiovascular outcome. Clin Res Cardiol 2018; 107:271-280. [PMID: 29453595 PMCID: PMC5869944 DOI: 10.1007/s00392-018-1202-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/11/2018] [Indexed: 12/03/2022]
Abstract
BACKGROUND This article about the emerging field of cardio-oncology highlights typical side effects of oncological therapies in the cardiovascular system, cardiovascular complications of malignancies itself, and potential preventive or therapeutic modalities. METHODS We performed a selective literature search in PubMed until September 2016. RESULTS Cardiovascular events in cancer patients can be frequently attributed to oncological therapies or to the underlying malignancy itself. Furthermore, many patients with cancer have pre-existing cardiovascular diseases that can be aggravated by the malignancy or its therapy. Cardiovascular abnormalities in oncological patients comprise a broad spectrum from alterations in electrophysiological, laboratory or imaging tests to the occurrence of thromboembolic, ischemic or rhythmological events and the impairment of left ventricular function or manifest heart failure. DISCUSSION A close interdisciplinary collaboration between oncologists and cardiologists/angiologists as well as an increased awareness of potential cardiovascular complications could improve clinical care of cancer patients and provides a basis for an improved understanding of underlying mechanisms of cardiovascular morbidity.
Collapse
Affiliation(s)
- Lisa M Tilemann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Markus B Heckmann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Hugo A Katus
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Lorenz H Lehmann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany.
| | - Oliver J Müller
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany.
- Department of Internal Medicine III, University of Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| |
Collapse
|
41
|
Kim K, Kim J, Ahn SH, Ha WS, Koo YJ, Kim DJ, Nam HS, Heo JH. Histopathological Findings of Intracranial Thrombi in Nonbacterial Thrombotic Endocarditis. J Stroke 2017; 19:367-369. [PMID: 29037008 PMCID: PMC5647627 DOI: 10.5853/jos.2017.00696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kyoungsub Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Mediplex Sejong Hospital, Incheon, Korea
| | - Jayoung Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Disease, Yonsei University Health System, Seoul, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwangju, Korea
| | - Woo Seok Ha
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Yu Jin Koo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
42
|
Lobo Ferreira T, Alves R, Judas T, Delerue MF. Marantic endocarditis and paraneoplastic pulmonary embolism. BMJ Case Rep 2017; 2017:bcr-2017-220217. [PMID: 28710195 PMCID: PMC5534972 DOI: 10.1136/bcr-2017-220217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 11/03/2022] Open
Abstract
Cancer is frequently associated with a hypercoagulable state. Almost 15% of patients with cancer will suffer a thromboembolic event during their clinical course. The aetiology of this hypercoagulable state is multifactorial and includes procoagulant factors associated with malignancy as well as the host's inflammatory response. Cancer-associated thrombophilia can present as venous thromboembolism, migratory superficial thrombophlebitis, arterial thrombosis, disseminated intravascular coagulation, thrombotic microangiopathy and rarely non-bacterial thrombotic endocarditis (NBTE). In this paper, we will describe an uncommon presentation of lung cancer on a non-smoker middle-aged woman, with recent diagnosis of pulmonary embolism, who develops malignant recurrent pleural effusion, NBTE with cutaneous and neurological manifestations, with a rapid evolution into shock, culminating in death. Diagnosis of NBTE requires a high degree of clinical suspicion. The mainstay of treatment is systemic anticoagulation to prevent further embolisation and underlying cancer control whenever is possible.
Collapse
Affiliation(s)
| | - Rosa Alves
- Department of Internal Medicine, Hospital Garcia de Orta, Almada, Portugal
| | - Tiago Judas
- Department of Internal Medicine, Hospital Garcia de Orta, Almada, Portugal
| | - Maria F Delerue
- Department of Internal Medicine, Hospital Garcia de Orta, Almada, Portugal
| |
Collapse
|
43
|
Achiha T, Takagaki M, Oe H, Sakai M, Matsui H, Nakanishi K, Ozaki T, Fujimoto Y, Yoshimine T, Nakanishi K, Kinoshita M. Voxel-Based Lesion Mapping of Cryptogenic Stroke in Patients with Advanced Cancer: A Detailed Magnetic Resonance Imaging Analysis of Distribution Pattern. J Stroke Cerebrovasc Dis 2017; 26:1521-1527. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/18/2017] [Accepted: 02/26/2017] [Indexed: 11/16/2022] Open
|
44
|
Parikh NS, Burch JE, Kamel H, DeAngelis LM, Navi BB. Recurrent Thromboembolic Events after Ischemic Stroke in Patients with Primary Brain Tumors. J Stroke Cerebrovasc Dis 2017. [PMID: 28647417 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Stroke mechanisms and the risk of recurrent thromboembolism are incompletely understood in patients with primary brain tumors. We sought to better delineate these important clinical features. METHODS We performed a retrospective cohort study of adults with primary brain tumors diagnosed with magnetic resonance imaging-confirmed acute ischemic stroke at the Memorial Sloan Kettering Cancer Center from 2005 to 2015. Study neurologists collected data on patients' cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier statistics were used to calculate cumulative outcome rates, and Cox hazards analysis was used to evaluate the association between potential risk factors and outcomes. RESULTS We identified 83 patients with primary brain tumors and symptomatic acute ischemic stroke. Median survival after index stroke was 2.2 years (interquartile range, .5-7.0). Tumors were mostly gliomas (72%) and meningiomas (13%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (18%). Small- or large-vessel disease or cardioembolism caused 13% of strokes, whereas 29% were cryptogenic. Cumulative recurrent thromboembolism rates were 11% at 30 days, 17% at 180 days, and 27% at 365 days, whereas cumulative recurrent stroke rates were 5% at 30 days, 11% at 180 days, and 13% at 365 days. We found no significant predictors of outcomes. CONCLUSION Patients with primary brain tumors generally develop strokes from rare mechanisms, and their risk of recurrent thromboembolism, including stroke, is high.
Collapse
Affiliation(s)
- Neal S Parikh
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Jaclyn E Burch
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.
| |
Collapse
|
45
|
Three-Month Outcomes Are Poor in Stroke Patients with Cancer Despite Acute Stroke Treatment. J Stroke Cerebrovasc Dis 2017; 26:809-815. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 09/20/2016] [Accepted: 10/19/2016] [Indexed: 12/12/2022] Open
|
46
|
|
47
|
Mitma AA, Varghese JG, Witt D, Zarich SW. Stroke and a valvular lesion in a patient with stage IV non-small cell lung cancer. BMJ Case Rep 2016; 2016:bcr-2016-215317. [PMID: 27247207 DOI: 10.1136/bcr-2016-215317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The mechanism and severity of stroke varies in the setting of malignancy. We report a case of a 68-year-old man with lung adenocarcinoma, who experienced acute neurological symptoms. Imaging studies showed multiple acute ischaemic infarcts in cerebral and cerebellar hemispheres. Further work up was consistent with non-bacterial thrombotic endocarditis (NBTE). We highlight, through a review of the literature, the importance of transoesophageal echocardiography (TOE) in defining the above diagnosis. The treatment of NBTE consists of systemic anticoagulation and therapy of the underlying malignancy. Enoxaparin is preferred over warfarin to achieve this goal. He received systemic targeted therapy with erlotinib. A TOE performed 8 months later showed complete resolution of the vegetation.
Collapse
Affiliation(s)
- Angel A Mitma
- Department of Internal Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jithin G Varghese
- Department of Internal Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - David Witt
- Yale University School of Medicine, New Haven, Connecticut, USA Yale Smilow Cancer Hospital, New Haven, Connecticut, USA
| | - Stuart W Zarich
- Yale University School of Medicine, New Haven, Connecticut, USA Department of Cardiology, Bridgeport Hospital, Bridgeport, Connecticut, USA
| |
Collapse
|
48
|
Greer DM, Homma S, Furie KL. Cardiac Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00032-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
49
|
Seki A, Fishbein M. Age-related Cardiovascular Changes and Diseases. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00002-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
50
|
Navi BB, Reiner AS, Kamel H, Iadecola C, Elkind MSV, Panageas KS, DeAngelis LM. Association between incident cancer and subsequent stroke. Ann Neurol 2015; 77:291-300. [PMID: 25472885 DOI: 10.1002/ana.24325] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/26/2014] [Accepted: 11/29/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE A study was undertaken to examine the association between incident cancer and the subsequent risk of stroke. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified patients with a new primary diagnosis of breast, colorectal, lung, pancreatic, or prostate cancer from 2001 through 2007. These patients were individually matched by age, sex, race, registry, and medical comorbidities to a group of Medicare enrollees without cancer, and each pair was followed through 2009. Validated diagnosis codes were used to identify a primary outcome of stroke. Cumulative incidence rates were calculated using competing risk survival statistics. RESULTS Among 327,389 pairs of cancer patients and matched controls, the 3-month cumulative incidence of stroke was generally higher in patients with cancer. Cumulative incidence rates were 5.1% (95% confidence interval [CI] = 4.9-5.2%) in patients with lung cancer compared to 1.2% (95% CI = 1.2-1.3%) in controls (p < 0.001), 3.4% (95% CI = 3.1-3.6%) in patients with pancreatic cancer compared to 1.3% (95% CI = 1.1-1.5%) in controls (p < 0.001), 3.3% (95% CI = 3.2-3.4%) in patients with colorectal cancer compared to 1.3% (95% CI = 1.2-1.4%) in controls (p < 0.001), 1.5% (95% CI = 1.4-1.6%) in patients with breast cancer compared to 1.1% (95% CI = 1.0-1.2%) in controls (p < 0.001), and 1.2% (95% CI = 1.1-1.3%) in patients with prostate cancer compared to 1.1% (95% CI = 1.0-1.2%) in controls (p = 0.085). Excess risks attenuated over time and were generally no longer present beyond 1 year. INTERPRETATION Incident cancer is associated with an increased short-term risk of stroke. This risk appears highest with lung, pancreatic, and colorectal cancers.
Collapse
Affiliation(s)
- Babak B Navi
- Department of Neurology, Weill Cornell Medical College, New York, NY; Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY; Departments of Neurology, Memorial Sloan Kettering Cancer Center, Columbia University, New York, NY
| | | | | | | | | | | | | |
Collapse
|